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Mugnai G, Velagic V, Malagù M, de Asmundis C, Tomasi L, Bolzan B, Chierchia GB, Ribichini FL, Ströker E, Bertini M. Zero fluoroscopy catheter ablation of premature ventricular contractions: a multicenter experience. J Interv Card Electrophysiol 2024; 67:827-836. [PMID: 38102499 DOI: 10.1007/s10840-023-01723-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Catheter ablation has become an established treatment option for premature ventricular complexes (PVCs). The use of fluoroscopy exposes patients and medical staff to potentially harmful stochastic and deterministic effects of ionizing radiations. We sought to analyze procedural outcomes in terms of safety and efficacy using a "zero fluoroscopy" approach for catheter ablation of PVCs. METHODS The present retrospective, multicenter, observational study included 131 patients having undergone catheter ablation of PVCs using "zero fluoroscopy" between 2019 and 2020 in four centers compared with another group who underwent the procedure with fluoroscopy. RESULTS Median age was 51.0 ± 15.9 years old; males were 77 (58.8%). Among the study population, 26 (19.8%) had a cardiomyopathy. The most frequent PVC origin was right ventricular outflow tract (55%) followed by the left ventricle (16%), LVOT and cusps (13.7%), and aortomitral continuity (5.3%). Acute suppression of PVC was achieved in 127 patients (96.9%). At 12 months, a complete success was documented in 109 patients (83.2%), a reduction in PVC burden in 18 patients (13.7%), and a failure was recorded in four patients (3.1%). Only two minor complications occurred (femoral hematoma and arteriovenous fistula conservatively treated). CONCLUSIONS The PVC ablation with a "zero" fluoroscopy approach appears to be a safe procedure with no major complications and good rates of success and recurrence in our multicenter experience.
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Affiliation(s)
- Giacomo Mugnai
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy.
| | - Vedran Velagic
- Department of Cardiovascular Diseases, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Michele Malagù
- Cardiology Unit, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Luca Tomasi
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Bruna Bolzan
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Flavio Luciano Ribichini
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Erwin Ströker
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Matteo Bertini
- Cardiology Unit, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
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Tran DC, Chung F. Ventricular arrhythmias originating from left ventricular summit: Salvage strategies after conventional ablation. J Arrhythm 2024; 40:226-227. [PMID: 38586841 PMCID: PMC10995560 DOI: 10.1002/joa3.12991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 04/09/2024] Open
Affiliation(s)
- Dat Cao Tran
- Heart Rhythm Center, Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Fa‐Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Department of MedicineNational Yang‐Ming Chiao‐Tung University School of MedicineTaipeiTaiwan
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3
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Futyma P, Bordignon S. Editorial to "Management of refractory intramural LV summit ventricular arrhythmia: Acute success using bipolar radiofrequency catheter ablation with recurrence". J Arrhythm 2024; 40:224-225. [PMID: 38586832 PMCID: PMC10995558 DOI: 10.1002/joa3.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/20/2024] [Indexed: 04/09/2024] Open
Affiliation(s)
- Piotr Futyma
- St. Joseph's Heart Rhythm CenterRzeszówPoland
- Medical CollegeUniversity of RzeszówRzeszówPoland
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus Der Goethe‐Universität Frankfurt Am MainFrankfurt am MainGermany
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4
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Enriquez A, Hanson M, Nazer B, Gibson DN, Cano O, Tokioka S, Fukamizu S, Sanchez Millan P, Hoyos C, Matos C, Sauer WH, Tedrow U, Romero J, Neira V, Futyma M, Futyma P. Bipolar ablation involving coronary venous system for refractory left ventricular summit arrhythmias. Heart Rhythm O2 2024; 5:24-33. [PMID: 38312200 PMCID: PMC10837170 DOI: 10.1016/j.hroo.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Catheter ablation of premature ventricular complexes (PVCs) and ventricular tachycardia (VT) from the left ventricular summit (LVS) may require advanced ablation techniques. Bipolar ablation from the coronary veins and adjacent endocardial structures can be effective for refractory LVS arrhythmias. Objective The aim of this study was to investigate the outcomes of bipolar ablation performed between the coronary venous system and adjacent endocardial left ventricular outflow tract (LVOT) or right ventricular outflow tract (RVOT). Methods This multicenter study included consecutive patients with LVS PVC/VT who underwent bipolar ablation between the anterior interventricular vein (AIV) or great cardiac vein (GCV) and the endocardial LVOT/RVOT after failed unipolar ablation. Ablation was started with powers of 10-20 W and uptitrated to achieve an impedance drop of at least 10%. Angiography was performed in all cases to confirm a safe distance (>5 mm) of the catheter from the major coronary arteries. Results Between 2013 and 2023, bipolar radiofrequency ablation between the AIV/GCV and the adjacent LVOT/RVOT was attempted in 20 patients (4 female; age 57 ± 16 years). Unipolar ablation from sites of early activation (AIV/GCV, LVOT, aortic cusps, RVOT) failed to effectively suppress the PVC/VT in all subjects. Bipolar ablation was delivered with a maximum power of 30 ± 8 W and total duration of 238 ± 217 s and led to acute PVC/VT elimination in all patients. No procedural-related complications occurred. Over a follow-up period of 30 ± 24 months, the freedom from arrhythmia recurrence was 85% (1 recurrence in the VT group and 2 in the PVC group). PVC burden was reduced from 22% ± 10% to 4% ± 8% (P <.001). Conclusion In cases of LVS PVC/VT refractory to unipolar ablation, bipolar ablation between the coronary venous system and adjacent endocardial LVOT/RVOT is safe and effective if careful titration of power and intraprocedural angiography are performed to ensure a safe distance from the coronary arteries.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Matthew Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Babak Nazer
- Division of Cardiology, University of Washington, Seattle, Washington
| | | | - Oscar Cano
- Division of Cardiology, Hospital Universitari Politècnic La Fe, Valencia, Spain
| | - Sayuri Tokioka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Pablo Sanchez Millan
- Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos Matos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Usha Tedrow
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jorge Romero
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Neira
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Marian Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
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5
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Bourquin L, Küffer T, Asatryan B, Badertscher P, Baldinger SH, Knecht S, Seiler J, Spies F, Servatius H, Kühne M, Noti F, Osswald S, Haeberlin A, Tanner H, Roten L, Reichlin T, Sticherling C. Validation of a clinical model for predicting left versus right ventricular outflow tract origin of idiopathic ventricular arrhythmias. Pacing Clin Electrophysiol 2023; 46:1186-1196. [PMID: 37616339 DOI: 10.1111/pace.14809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/26/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Prediction of the chamber of origin in patients with outflow tract ventricular arrhythmias (OTVA) remains challenging. A clinical risk score based on age, sex and presence of hypertension was associated with a left ventricular outflow tract (LVOT) origin. We aimed to validate this clinical score to predict an LVOT origin in patients with OTVA. METHODS In a two-center observational cohort study, unselected patients undergoing catheter ablation (CA) for OTVA were enrolled. All procedures were performed using an electroanatomical mapping system. Successful ablation was defined as a ≥80% reduction of the initial overall PVC burden after 3 months of follow-up. Patients with unsuccessful ablation were excluded from this analysis. RESULTS We included 187 consecutive patients with successful CA of idiopathic OTVA. Mean age was 52 ± 15 years, 102 patients (55%) were female, and 74 (40%) suffered from hypertension. A LVOT origin was found in 64 patients (34%). A score incorporating age, sex and presence of hypertension reached 73% sensitivity and 67% specificity for a low (0-1) and high (2-3) score, to predict an LVOT origin. The combination of one ECG algorithm (V2 S/V3 R-index) with the clinical score resulted in a sensitivity and specificity of 81% and 70% for PVCs with R/S transition at V3 . CONCLUSION The published clinical score yielded a lower sensitivity and specificity in our cohort. However, for PVCs with R/S transition at V3, the combination with an existing ECG algorithm can improve the predictability of LVOT origin.
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Affiliation(s)
- Luc Bourquin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Thomas Küffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Samuel H Baldinger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Knecht
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Spies
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Kühne
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Sticherling
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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6
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Arps K, Barnett AS, Koontz JI, Pokorney SD, Jackson KP, Bahnson TD, Piccini JP, Sun AY. Use of Ripple mapping to enhance localization and ablation of outflow tract premature ventricular contractions. J Cardiovasc Electrophysiol 2023; 34:1552-1560. [PMID: 37293826 DOI: 10.1111/jce.15963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Accurate localization of septal outflow tract premature ventricular contractions (PVCs) is often difficult due to frequent mid-myocardial or protected origin. Compared with traditional activation mapping, CARTO Ripple mapping provides visualization of all captured electrogram data without assignment of a specific local activation time and thus may enhance PVC localization. METHODS Electroanatomic maps for consecutive catheter ablation procedures for septal outflow tract PVCs (July 2018-December 2020) were analyzed. For each PVC, we identified the earliest local activation point (EA), defined by the point of maximal -dV/dt in a simultaneously recorded unipolar electrogram, and the earliest Ripple signal (ERS), defined as the earliest point at which three grouped simultaneous Ripple bars appeared in late diastole. Immediate success was defined as full suppression of the clinical PVC. RESULTS Fifty-seven unique PVCs in 55 procedures were included. When ERS and EA were in the same chamber (RV, LV, or CS), the odds ratio for the successful procedure was 13.1 (95% confidence interval [CI] 2.2-79.9, p = .005). Discordance between sites was associated with a higher likelihood of needing multi-site ablation (odds ratio [OR] 7.9 [1.4-4.6; p = .020]). Median EA-ERS distance in successful versus unsuccessful cases was 4.6 mm (interquartile range 2.9-8.5) versus 12.5 mm (7.8-18.5); (p = .020). CONCLUSION Greater EA-ERS concordance was associated with higher odds of single-site PVC suppression and successful septal outflow tract PVC ablation. Visualization of complex signals via automated Ripple mapping may offer rapid localization information complementary to local activation mapping for PVCs of mid-myocardial origin.
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Affiliation(s)
- Kelly Arps
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam S Barnett
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Prisma Health, Greenville, South Carolina, USA
| | - Jason I Koontz
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin P Jackson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Tristram D Bahnson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Albert Y Sun
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
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7
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Kuniewicz M, Budnicka K, Dusza M, Jakob N, Cholewa N, Defonseka R, Gosnell M, Wadhwa T, Walocha J, Dobrzynski H, Hołda M. Gross anatomic relationship between the human left atrial appendage and the left ventricular summit region: implications for catheter ablation of ventricular arrhythmias originating from the left ventricular summit. J Interv Card Electrophysiol 2023; 66:301-310. [PMID: 35262858 DOI: 10.1007/s10840-022-01172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The left ventricular summit (LVS) is a source of difficult-to-treat arrhythmias because of anatomical limitations. The aim of this study was to perform detailed research of the left atrial appendage (LAA) anatomy of cadaveric hearts to analyze their complex anatomy and coverage of the LVS. METHODS AND RESULTS Eighty human formalin fixed hearts (mean age 44.4 ± 15.5, 27.5% females) were investigated. Each LAA size, type, and its relationship to the LVS were analyzed, as well as possible access sites for mapping/ablating electrode. Four types of LAA were observed over two LVS sites that are either accessible or not. The highest coverage over an inaccessible LVS area was observed in the Broccoli type, followed by the Windsock then the Chicken Wing and finally the Cactus types; over the accessible area of the LVS was observed in the Windsock, then in the Chicken Wing, then in the Cactus, and finally in the Broccoli types. The attainable coverage for electrode access is diminished from 25 to 65% because of the complex pectinate muscles and sharp angles. The highest density of the LAA floor made by pectinate muscles can be found in the Broccoli type (p < 0.005), while the Chicken Wing had the highest number of paper-thin-like pouches. CONCLUSIONS The LAA appears to be a promising entry for ablation-qualified patients with the LV summit originate arrhythmias. The complex internal structure of the LAA may complicate ablation procedures. More prominent appendages are promising in more extensive mapping areas over the LVS.
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Affiliation(s)
- M Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland. .,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Dusza
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Cholewa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - R Defonseka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - T Wadhwa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - H Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - M Hołda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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8
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Te-Rosano ALD, Chung FP, Lin YJ, Chen SA. Outcomes of Catheter Ablation of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:85-92. [PMID: 36774140 DOI: 10.1016/j.ccep.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit (LVS) is the area in the highest portion of the left ventricular epicardium, bounded by the left coronary arteries and the coronary venous circulation, and can be surrounded by thick epicardial fat that may preclude epicardial ablation. Ablation of LVS ventricular arrhythmias (VA) can be achieved from adjacent structures with good success rates. The long-term freedom from LVS VA recurrence remains variable. This article reviews the spatial and anatomic relationship of the structures surrounding the LVS, which provide vantage points for ablation, and the acute and long-term outcomes of different ablation approaches in LVS VA ablation.
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Affiliation(s)
- Abigail Louise D Te-Rosano
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; HB Calleja Heart and Vascular Institute, St. Luke's Medical Center, 279 E. Rodriguez Sr. Avenue, Quezon City 1112, Philippines
| | - Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan.
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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9
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Hanson MG, Enriquez A. Deductive Electrocardiographic Analysis of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:9-14. [PMID: 36774141 DOI: 10.1016/j.ccep.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit is a source of idiopathic ventricular arrhythmias and presents distinct challenges for mapping and ablation. These arrhythmias are typically targeted from the distal coronary venous system or most often from endocardial vantage points such as the left coronary cusp, basal left ventricle or septal right ventricular outflow tract. In this article, we review the electrocardiographic patterns that suggest a possible origin from the left ventricular summit and the features that may help to predict the most likely site of successful ablation.
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Affiliation(s)
- Matthew G Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada.
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10
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Restrepo AJ, Saenz Morales LC. Preventing Complications During Mapping and Ablation of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:93-109. [PMID: 36774142 DOI: 10.1016/j.ccep.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit is a site of origin for idiopathic ventricular arrhythmias. With advancements in mapping and ablation techniques, sites previously considered inaccessible can now be approached. Anatomical knowledge of the 3-dimensional landmarks of this space is important, as critical structures reside within its boundaries and are potentially liable to collateral injury during ablation. This article reviews reported complications from ablation of ventricular arrhythmias arising from the left ventricular summit and its vicinity and discusses the pros and cons of different ablation technique and the role of an individualized anatomical approach to reduce procedural related complications and improve outcomes.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA; University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Luis Carlos Saenz Morales
- International Arrhythmia Center, Fundacion CardioInfantil, Bogota, Colombia; Fundacion CardioInfantil, Instituto de Cardiologia, Calle 163 #13b-60, Bogota, Colombia
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11
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Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit. Card Electrophysiol Clin 2023; 15:25-30. [PMID: 36774133 DOI: 10.1016/j.ccep.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The left ventricular summit (LVS) is the highest point of the left ventricular epicardium, and ventricular arrhythmias originating from this area accounts for 10% to 15% of idiopathic outflow tract ventricular arrhythmias. Direct epicardial ablation of outflow tract ventricular arrhythmias arising from the LVS is successful only in a minority of patients because of close proximity to the coronary artery or thick epicardial fat. Therefore, alternative strategies should be prioritized before performing epicardial approach. When performed, electrocardiogram characteristics suggestive of the site of origin to be the accessible area within the LVS needs be evaluated to avoid ineffective epicardial approach.
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12
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Futyma P, Sauer WH. Bipolar Radiofrequency Catheter Ablation of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:57-62. [PMID: 36774137 DOI: 10.1016/j.ccep.2022.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Challenging anatomic and morphologic conditions of the left ventricular (LV) summit architecture and its surrounding sites may prevent sufficient heating of the targeted area during standard radiofrequency catheter ablation. Bipolar ablation can result in higher likelihood of efficacy for ablation of LV summit arrhythmias from inaccessible regions and increase the chance of achieving a transmural lesion. In this review, the authors describe the present approaches for bipolar ablation of the LV summit arrhythmias refractory to standard approaches.
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Affiliation(s)
- Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Anny Jagiellonki 17, Rzeszów 35-623, Poland.
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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13
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Zhang Z, Zhang Z, Zou C, Pei Z, Yang Z, Wu J, Sun S, Gu F. ECGNet: An Efficient Network for Detecting Premature Ventricular Complexes Based on ECG Images. IEEE Trans Biomed Eng 2023; 70:446-458. [PMID: 35881595 DOI: 10.1109/tbme.2022.3193906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preoperative prediction of the origin site of premature ventricular complexes (PVCs) is critical for the success of operations. However, current methods are not efficient or accurate enough. In addition, among the proposed strategies, there are few good prediction methods for electrocardiogram (ECG) images combined with deep learning aspects. METHODS We propose ECGNet, a new neural network for the classification of 12-lead ECG images. In ECGNet, 609 ECG images from 310 patients who had undergone successful surgery in the Division of Cardiology, the First Affiliated Hospital of Soochow University, are utilized to construct the dataset. We adopt dense blocks, special convolution kernels and divergent paths to improve the performance of ECGNet. In addition, a new loss function is designed to address the sample imbalance situation, whose cause is the uneven distribution of cases themselves, which often occurs in the medical field. We also conduct extensive experiments in terms of network prediction accuracy to compare ECGNet with other networks, such as ResNet and DarkNet. RESULTS Our ECGNet achieves extremely high prediction accuracy (91.74%) and efficiency with very small datasets. Our newly proposed loss function can solve the problem of sample imbalance during the training process. CONCLUSION The proposed ECGNet can quickly and accurately realize the multiclassification of PVCs after training with little data. Our network has the potential to be helpful to doctors with a preoperative diagnosis of PVCs. We will continue to collect similar cases and perfect our network structure to further improve the accuracy of our network's prediction.
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Futyma P, Zarębski Ł, Chen S, Enriquez A, Pürerfellner H, Santangeli P. Risk Assessment and Management of Outflow Tract Arrhythmias Refractory to Prior Treatments. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00712-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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15
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A Four-Stepwise Electrocardiographic Algorithm for Differentiation of Ventricular Arrhythmias Originated from Left Ventricular Outflow Tract. J Clin Med 2022; 11:jcm11216398. [PMID: 36362626 PMCID: PMC9653710 DOI: 10.3390/jcm11216398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022] Open
Abstract
Several electrocardiographic algorithms have been proposed to identify the site of origin for the ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) versus right ventricular outflow tract. However, the electrocardiographic criteria for distinguishing VAs originated from the different sites of LVOT is lacking. We aimed to develop a simple and efficient ECG algorithm to differentiate LVOT VAs originated from the aortic root, AMC and LV summit. We analyzed 12-lead ECG characteristics of 68 consecutive patients who underwent successful radiofrequency catheter ablation of symptomatic VAs from LVOT. Patients were divided into RCC (right coronary cusp) group (n = 8), the L-RCC (the junction between the LCC and RCC) group (n = 21), the LCC (left coronary cusp) group (n = 24), the aortomitral continuity (AMC) group (n = 9) and the LV summit group (n = 6) according to the final ablation sites. Measurements with the highest diagnostic performance were modeled into a 4-stepwise algorithm to discriminate LVOT VAs. The performance of this novel algorithm was prospectively tested in a validation cohort of 43 consecutive patients undergoing LVOT VAs ablation. Based on the accuracy of AUC, a 4-stepwise ECG algorithm was developed. First, the QS duration in aVL > 134 ms was used to distinguish VAs from AMC, LV summit and VAs from aortic root (80% sensitivity and 76% specificity). Second, the R duration in II > 155 ms was used to differentiate VAs from LV summit and VAs from AMC (67% sensitivity and 56% specificity). Third, the ratio of III/II < 0.9 was used to discriminate VAs from RCC and VAs from LCC, L-RCC (82% sensitivity and 63% specificity). Fourth, the QS duration of aVR > 130 ms was used to discern VAs from LCC and VAs from L-RCC (75% sensitivity and 62% specificity). In the prospective evaluation, our 4-stepwise ECG algorithm exhibited a good predictive value. We have developed a novel and simple 4-stepwise ECG algorithm with good predictive value to discriminate the AVs from different sites of LVOT.
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16
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Bipolar Ablation Using Large-Tip Catheters as a Return Electrode: Lessons Learned From Clinical Scenarios. JACC Clin Electrophysiol 2022; 8:1163. [PMID: 36137724 DOI: 10.1016/j.jacep.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022]
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17
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Nakamura K, Sasaki T, Kimura K, Haraguchi Y, Minami K, Naito S. Successful elimination of ventricular arrhythmias by radiofrequency ablation within the left ventricular summit communicating vein using a 5F ablation catheter. HeartRhythm Case Rep 2022; 8:771-775. [PMID: 36618603 PMCID: PMC9811025 DOI: 10.1016/j.hrcr.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Kohki Nakamura
- Address reprint requests and correspondence: Dr Kohki Nakamura, Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004 Japan.
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18
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Electrocardiogram Parameters That Affect the Success Rate of Radiofrequency Ablation in Patients with Outflow Tract Ventricular Premature Complexes. Cardiovasc Ther 2022; 2022:8160144. [PMID: 35936796 PMCID: PMC9337924 DOI: 10.1155/2022/8160144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/14/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives. The objectives of this study are to assess the efficacy of radiofrequency catheter ablation (RFCA) in patients with outflow tract (OT) ventricular premature complexes (VPCs) and to explore the electrocardiographic (ECG) features of initially successful procedures. Methods. Based on the outcome of ablation, 154 consecutive patients with OT-VPCs who underwent RFCA from January 2017 to December 2019 were divided into two groups. The rate of successful procedures and the ECG features were analyzed and compared between the two groups. Results. The highest success rate was found in patients with VPCs from the right ventricular outflow tract (RVOT), and the lowest success rate was evident among patients with complexes from both the RVOT and the left ventricular OT (LVOT). The patients with successful procedures (136) reflected a lower pseudo delta wave ratio (16.2% vs. 44.4%,
), a smaller R-wave amplitude in lead V1 (V1) (
mV vs.
mV,
), shorter intrinsicoid deflection time in lead V2 (V2) (
ms vs.
ms,
), a shorter RS duration in V2 (
ms vs.
ms,
), and smaller R/S-waveratios in V2. Furthermore, multivariate analysis demonstrated that RS duration in V2 was above 109.17 ms and R/S ratio in V2 was above 0.28, forecasting a failed procedure. Conclusions. The ECG predictors of failed ablation were characterized by RS duration and R/S ratio in V2.
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19
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Zhou B, Yu J, Ju W, Li X, Zhang F, Chen H, Li M, Gu K, Xie X, Cheng D, Wang X, Wu Y, Zhou J, Zhang B, Kojodjojo P, Cao K, Yang B, Chen M. Bipolar Catheter Ablation Strategies for Outflow Tract Ventricular Arrhythmias Refractory to Unipolar Ablation. J Cardiovasc Electrophysiol 2022; 33:1769-1778. [PMID: 35634859 DOI: 10.1111/jce.15579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/02/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Benjun Zhou
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
- Department of CardiologyThe Affiliated Jiangning Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Jinbo Yu
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Weizhu Ju
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Xiaorong Li
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Fengxiang Zhang
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Hongwu Chen
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Mingfang Li
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Kai Gu
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Xin Xie
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Dian Cheng
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Xuecheng Wang
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Yizhang Wu
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Jian Zhou
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Baowei Zhang
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Pipin Kojodjojo
- Department of CardiologyNg Teng Fong General HospitalSingaporeSingapore
| | - Kejiang Cao
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Bing Yang
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Minglong Chen
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
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20
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Chang TY, Chen KW, Liu CM, Chang SL, Lin YJ, Lo LW, Hu YF, Chung FP, Lin CY, Kuo L, Chen SA. A High-Precision Deep Learning Algorithm to Localize Idiopathic Ventricular Arrhythmias. J Pers Med 2022; 12:jpm12050764. [PMID: 35629186 PMCID: PMC9145898 DOI: 10.3390/jpm12050764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/04/2022] Open
Abstract
Background: An accurate prediction of ventricular arrhythmia (VA) origins can optimize the strategy of ablation, and facilitate the procedure. Objective: This study aimed to develop a machine learning model from surface ECG to predict VA origins. Methods: We obtained 3628 waves of ventricular premature complex (VPC) from 731 patients. We chose to include all signal information from 12 ECG leads for model input. A model is composed of two groups of convolutional neural network (CNN) layers. We chose around 13% of all the data for model testing and 10% for validation. Results: In the first step, we trained a model for binary classification of VA source from the left or right side of the chamber with an area under the curve (AUC) of 0.963. With a threshold of 0.739, the sensitivity and specification are 90.7% and 92.3% for identifying left side VA. Then, we obtained the second model for predicting VA from the LV summit with AUC is 0.998. With a threshold of 0.739, the sensitivity and specificity are 100% and 98% for the LV summit. Conclusions: Our machine learning algorithm of surface ECG facilitates the localization of VPC, especially for the LV summit, which might optimize the ablation strategy.
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Affiliation(s)
- Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 112303, Taiwan
| | - Ke-Wei Chen
- Department of BioMedical Engineering, National Cheng Kung University, Tainan City 701401, Taiwan;
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Correspondence: ; Tel.: +886-2-7735-3832; Fax: +886-2-2872-4082
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (T.-Y.C.); (C.-M.L.); (Y.-J.L.); (L.-W.L.); (Y.-F.H.); (F.-P.C.); (C.-Y.L.); (L.K.); (S.-A.C.)
- Institute of Cardiovascular Research, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung 40705, Taiwan
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21
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Garg L, Daubert T, Lin A, Dhakal B, Santangeli P, Schaller R, Hyman MC, Kumareswaran R, Arkles J, Nazarian S, Lin D, Riley MP, Supple GE, Frankel DS, Zado E, Callans DJ, Marchlinski FE, Dixit S. Utility of Prolonged Duration Endocardial Ablation for Ventricular Arrhythmias Originating From the Left Ventricular Summit. JACC Clin Electrophysiol 2022; 8:465-476. [PMID: 35450601 DOI: 10.1016/j.jacep.2021.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 12/11/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study sought to explore whether prolonged duration (PD) radiofrequency ablation (RFA) from adjacent endocardial locations can improve catheter ablation (CA) outcomes of left ventricular summit (LVS) ventricular arrhythmias (Vas). BACKGROUND CA of VAs originating from the LVS region can be challenging. METHODS Patients undergoing CA of LVS VAs from January 1, 2015, to December 31, 2019, were included. Standard RFA approach involved incremental power titration (20-45 W) over 60-120 seconds with irrigated tip catheter to achieve 10%-12% impedance drop. Prolonged duration RFA involved similar power titration; however, lesion application was extended beyond 120 seconds (maximum 5 minutes). Lesions were confined to lowest aspect of aortic cusps and/or subvalvular LV outflow tract region (≤0.5 cm from the valve). Procedural success was defined as suppression of VA ≥30 minutes postablation and clinical success as no arrhythmia symptoms on follow-up and >80% reduction of VA burden on postprocedure monitor. RESULTS This study included 102 patients (60±14 years old, 62% male): standard RFA in 80 and PD RFA in 38. Procedural success was achieved in 54 patients with standard and 32 patients with PD RFA (68% vs 84%; P = 0.05). Short-term clinical success was achieved in 48 patients (60%) with standard and 30 patients (79%) with PD RFA (P = 0.04). Two pericardial effusions occurred (1 in each group) and no steam pops were noted. Patients in whom standard RFA was successful were more likely to have R/S ratio >1 or absence of qS in lead I (odds ratio: 3.35; 95% CI: 1.20-9.35; P = 0.03). CONCLUSIONS Prolonged duration RFA from adjacent endocardial locations is a safe and effective technique for successfully targeting challenging LVS VAs that fail standard RFA.
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Affiliation(s)
- Lohit Garg
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas Daubert
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aung Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bishnu Dhakal
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica Zado
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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22
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Darma A, Bertagnolli L, Torri F, Paetsch I, Jahnke C, Dinov B, Hindricks G, Arya A. LV Pseudoaneurysm With Concomitant Mitral Valve Defect After LV Summit Ablation: A Rare Late Complication. JACC Case Rep 2021; 3:1756-1759. [PMID: 34825204 PMCID: PMC8603023 DOI: 10.1016/j.jaccas.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
A 25-year-old male patient with highly symptomatic, monomorphic, premature ventricular contractions presented for repeat ablation after failed endocardial ablation. Three weeks after excessive endocardial and epicardial ablation on the left ventricular summit, the patient was admitted again with tamponade following a pseudoaneurysm on the ablation site. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Angeliki Darma
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Livio Bertagnolli
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Federica Torri
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Ingo Paetsch
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Cosima Jahnke
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
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23
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Look left, look right, look left again. Heart Rhythm 2021; 18:2158-2159. [PMID: 34509636 DOI: 10.1016/j.hrthm.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/20/2022]
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24
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Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance. Diagnostics (Basel) 2021; 11:diagnostics11081423. [PMID: 34441357 PMCID: PMC8393416 DOI: 10.3390/diagnostics11081423] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023] Open
Abstract
The left ventricular summit (LVS) is a triangular area located at the most superior portion of the left epicardial ventricular region, surrounded by the two branches of the left coronary artery: the left anterior interventricular artery and the left circumflex artery. The triangle is bounded by the apex, septal and mitral margins and base. This review aims to provide a systematic and comprehensive anatomical description and proper terminology in the LVS region that may facilitate exchanging information among anatomists and electrophysiologists, increasing knowledge of this cardiac region. We postulate that the most dominant septal perforator (not the first septal perforator) should characterize the LVS definition. Abundant epicardial adipose tissue overlying the LVS myocardium may affect arrhythmogenic processes and electrophysiological procedures within the LVS region. The LVS is divided into two clinically significant regions: accessible and inaccessible areas. Rich arterial and venous coronary vasculature and a relatively dense network of cardiac autonomic nerve fibers are present within the LVS boundaries. Although the approach to the LVS may be challenging, it can be executed indirectly using the surrounding structures. Delivery of the proper radiofrequency energy to the arrhythmia source, avoiding coronary artery damage at the same time, may be a challenge. Therefore, coronary angiography or cardiac computed tomography imaging is strongly recommended before any procedure within the LVS region. Further research on LVS morphology and physiology should increase the safety and effectiveness of invasive electrophysiological procedures performed within this region of the human heart.
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25
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Futyma P, Chen S. Ablation Target Out of Range: A Journey Deep Into the Interventricular Septum. JACC Case Rep 2021; 3:1125-1127. [PMID: 34471896 PMCID: PMC8314120 DOI: 10.1016/j.jaccas.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Piotr Futyma
- Department of Cardiology, St Joseph’s Heart Rhythm Center, Rzeszów, Poland
| | - Shaojie Chen
- Department Kardiologe, Markus Krankenhaus, Cardioangiologisches Centrum Bethanien (CCB), Frankfurt am Main, Germany
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26
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Kamioka M, Hijioka N, Nodera M, Yamada S, Kaneshiro T, Takeishi Y. Electrophysiological properties and involvement of anatomical factors for the prediction of intramural origin in patients with ventricular tachyarrhythmia arising from the left ventricular outflow tract. J Interv Card Electrophysiol 2021; 63:115-123. [PMID: 33564988 DOI: 10.1007/s10840-021-00959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To elucidate the electrophysiological predictors of the intramural origins of left ventricular outflow tract-ventricular tachyarrhythmias (LVOT-VAs), and to clarify the involvement of anatomical factors. METHODS Twenty-nine successfully ablated LVOT-VAs patients with origins in the aortomitral continuity (AMC) (n = 8), aortic sinus of valsalva (ASV) (n = 9), great cardiac vein (GCV) (n = 5), and intramural myocardium (n = 7) were enrolled. Intramural origins were defined as when effective ablation from AMC and epicardium (ASV and/or GCV) was needed. The local activation time difference (LATD) was calculated as follows: (earliest AMC activation) - (earliest epicardial activation), and was presented as an absolute value. Electrophysiological parameters and anatomical factors predisposing the intramural origins were investigated. RESULTS LATD of intramural origins was significantly shorter than that of AMC and GCV (4.5 ± 2.6 vs. 12.1 ± 7.4 vs. 17.4 ± 4.7, P < 0.05), respectively. In multivariate logistic regression analysis, LATD was associated with intramural origins (odds ratio: 0.711, confidence interval: 0.514-0.985, P = 0.040). ROC analysis revealed LATD of 7 ms as cut-off value. In computed tomography analysis, some patients who had thick fat tissue below the GCV, and an unusual GCV running pattern might be misdiagnosed as intramural origins. CONCLUSION LATD ≤ 7 ms was associated with intramural origins, but with some anatomical limitations.
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Affiliation(s)
- Masashi Kamioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan.
| | - Naoko Hijioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shinya Yamada
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kaneshiro
- Department of Arrhythmia and Cardiac Pacing, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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Anatomic approach with bipolar ablation between the left pulmonic cusp and left ventricular outflow tract for left ventricular summit arrhythmias. Heart Rhythm 2020; 17:1519-1527. [DOI: 10.1016/j.hrthm.2020.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/23/2022]
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Liao H, Wei W, Tanager KS, Miele F, Upadhyay GA, Beaser AD, Aziz Z, Nayak HM, Ozcan C, Nishimura T, Jiang R, Shatz D, Husain AN, Tung R. Left ventricular summit arrhythmias with an abrupt V 3 transition: Anatomy of the aortic interleaflet triangle vantage point. Heart Rhythm 2020; 18:10-19. [PMID: 32707175 DOI: 10.1016/j.hrthm.2020.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND While early precordial electrocardiographic (ECG) characteristics are useful to differentiate left-sided from the right-sided outflow tract ventricular arrhythmia (OTVA), few patterns predict an origin from the septal margin of the left ventricular (LV) summit. OBJECTIVE The purpose of this study was to report mapping and ablation characteristics of a new ECG pattern with left bundle branch morphology and an abrupt R-wave transition in lead V3 (ATV3). METHODS Over a 3-year period, 78 consecutive patients (mean age 57±15 years; 35% female) with OTVA were referred for mapping and ablation. Twenty patients (26%) exhibited an ATV3 pattern, of whom 65% failed prior ablation. RESULTS Ninety-two percent of patients with ATV3 that underwent simultaneous epicardial and endocardial mapping demonstrated an intramural or epicardial site of origin. Eighty percent of OTVA with ATV3 was eliminated by ablation from the vantage point of the interleaflet triangle below the right-left coronary junction. The ATV3 pattern showed higher sensitivity, specificity, predictive value, and accuracy than validated ECG criteria (notch or "w" pattern in lead V1, qrS pattern in leads V1 through V3, and pattern break V2) for predicting successful ablation in the region of the anterior LV ostium. At 12±11 months, freedom from ventricular arrhythmia recurrence was 89% and 82% in the ATV3 and control groups, respectively. CONCLUSION ATV3 is a simple and distinct ECG pattern indicative of a site of origin from the septal margin of the LV summit. The right-left aortic interleaflet triangle vantage point was effective to eliminate OTVA with ATV3 that overwhelmingly exhibited the earliest activation from the epicardium or mid-myocardium. Test characteristics for ATV3 were superior to ECG patterns validated for the anterior LV ostium.
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Affiliation(s)
- Hongtao Liao
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China; Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Wei Wei
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China
| | - Kevin S Tanager
- Department of Pathology, Department of Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Frank Miele
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid Aziz
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Takuro Nishimura
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Ruhong Jiang
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Dalise Shatz
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Aliya N Husain
- Department of Pathology, Department of Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China; Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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